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Question

Difficulty: MediumSensory and Perceptual Alterations

An older adult client with profound bilateral hearing loss is admitted to a private room under strict contact precautions. On the third day of hospitalization, the client reports hearing a deceased spouse calling their name from the hallway. The client's vital signs are stable, and they remain fully oriented to person, place, and time. Which of the following is the most appropriate nursing action to address the client's sensory alteration?

  1. Increase meaningful visual and environmental stimuli by opening the window blinds during daylight hours.Answer
  2. B
    Inform the client that their spouse is deceased and logically explain why the voice is not real.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to assess the client's mental status every two hours.
  4. D
    Document the reported auditory hallucination as an expected physiological change associated with advanced age.

Answer

Increase meaningful visual and environmental stimuli by opening the window blinds during daylight hours.
The client is experiencing sensory deprivation due to the combination of profound hearing loss, placement in a private room, and strict isolation precautions. When the brain receives inadequate sensory input, it may generate its own stimuli, which often manifests as hallucinations. Because the client is fully oriented, acute delirium is less likely. The most appropriate nursing action is to increase meaningful environmental stimuli. Opening the window blinds provides natural light and visual orientation to the day-night cycle, which helps compensate for the severe auditory deficit.

Step-by-Step Solution

1
Analyze the clinical presentation.
The client has a pre-existing sensory deficit (hearing loss), is physically isolated (private room, contact precautions), and is experiencing auditory hallucinations while remaining cognitively intact.
Identifying the root cause of the perceptual alteration is necessary to determine the appropriate nursing intervention.
2
Identify the primary nursing problem.
The client is experiencing sensory deprivation.
Isolation and sensory deficits severely reduce meaningful environmental input, leading the brain to generate its own stimuli, which can manifest as hallucinations.
3
Select the intervention that addresses the root cause.
Providing visual stimuli (such as opening the window blinds) compensates for auditory deficits and combats the deprivation.
Increasing meaningful sensory input resolves the underlying deprivation safely, avoiding nontherapeutic communication or unauthorized delegation.

Key Concept

Sensory Deprivation in Isolated Clients
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Topics

Sensory and Perceptual Alterations

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